Eur J Appl Physiol (2015) 115:365–372

DOI 10.1007/s00421-014-3023-6

ORIGINAL ARTICLE

Prediction of peak oxygen uptake from ratings of perceived

exertion during a sub-maximal cardiopulmonary exercise test
in patients with chronic obstructive pulmonary disease
Jérémy B. Coquart · Roger G. Eston ·
Frédéric Lemaître · Frédéric Bart · Claire Tourny ·
Jean-Marie Grosbois 

Received: 21 May 2014 / Accepted: 10 October 2014 / Published online: 18 October 2014
© Springer-Verlag Berlin Heidelberg 2014

Abstract  patients (r ≥ 0.89; P < 0.001). The bias and 95 % limits of

Purpose  We assessed the validity of predicting peak oxy-
gen uptake (V̇ O2 peak) from the relationship between oxy-
gen uptake (V̇ O2) and overall ratings of perceived exertion
(RPE) obtained during the initial stages of a cardiopulmo-
nary exercise test (CPET).
Method  Fifteen healthy participants and 18 patients with
chronic obstructive pulmonary disease (COPD) performed
a maximal CPET, during which V̇ O2 and RPE were meas-
ured until RPE15.
Results Individual regressions between V̇ O2 and
RPE≤15 were extrapolated to RPE19 to predict V̇ O2
peak. Mean actual and predicted V̇ O2 peak were not sig-
nificantly different in healthy women (18.9 ± 4.1 vs.
20.4 ± 4.5 mL kg−1 min−1, respectively) and men (28.9 ± 7.8
vs. 29.7 ± 8.5 mL kg−1 min−1, respectively), or in women
(15.2 ± 4.7 vs. 15.8 ± 5.0 mL kg−1 min−1, respectively) and
men (16.2 ± 4.4 vs. 17.4 ± 5.4 mL kg−1 min−1, respectively)
with COPD (P = 0.067). Moreover, actual and predicted V̇ O2
peak were highly correlated in healthy participants and COPD
Communicated by Jean-René Lacour.
agreement were −1.0 ± 4.0 and −1.0 ± 4.6 mL kg−1 min−1
for healthy and COPD participants, respectively.
Conclusion  V̇ O2 peak can be predicted with acceptable
accuracy in healthy participants and patients with COPD
from the individual relationship between V̇ O2 and RPE≤15.
Keywords  Effort perception · Estimation · Respiratory
disease · Dyspnea · Physical fitness
Abbreviations
ANOVA Analysis of variance
COPD Chronic obstructive pulmonary disease
CPET Cardiopulmonary exercise test
CR-10 Borg category-ratio 10 scale
FEV1 Forced expiratory volume in 1 s
FVC Forced vital capacity
LoA95 % 95 % limits of agreement
RPE Ratings of perceived exertion
SD Standard deviations
V̇ O2 peak Peak oxygen uptake
V̇ O2 Oxygen uptake

J. B. Coquart · F. Lemaître · C. Tourny  R. G. Eston 

Faculty of Sport Sciences, EA 3832, CETAPS, College of Life and Environmental Sciences,
University of Rouen, Mont Saint Aignan, France University of Exeter, Sport and Health Sciences, Exeter, UK

J. B. Coquart (*)  F. Bart 
Faculté des Sciences du Sport et de l’Education Physique, Department of Pneumology, Germon and Gauthier Hospital,
CETAPS, Boulevard Siegfried, 76821 Mont Saint Aignan Cedex, Béthune, France
France
e-mail: jeremy.coquart@voila.fr J.-M. Grosbois 
Department of Effort Rehabilitation, Germon and Gauthier
R. G. Eston  Hospital, Béthune, France
Sansom Institute for Health Research,
School of Health Sciences, University of South Australia, J.-M. Grosbois 
Adelaide, Australia Formaction Santé, Perenchies, France

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Introduction
It is common practice for respiratory clinicians and physi-
ologists to use the modified Borg (1982) category-ratio 10
scale (CR-10) to assess dyspnea during cardiopulmonary
exercise testing (CPET) in patients with chronic obstruc-
tive pulmonary disease (COPD) (O’Donnell et al. 1998).
The curvilinear scale (i.e., CR-10 scale) is generally
regarded as suitable for assessing dyspnea during CPET
(O’Donnell et al. 2009), as dyspnea does not increase lin-
early during CPET. However, prior to the development of
the CR-10 scale, the Borg (1970) 6–20 ratings of perceived
exertion (RPE) scale was well established. The RPE scale
is different from the CR-10 scale in that the scale values
are designed to grow linearly with exercise intensity (e.g.,
velocity or power output) during CPET, while CR-10 val-
ues follow a curvilinear function (Borg 1998). Moreover,
as several physiological variables (e.g., heart rate: HR and
oxygen uptake: V̇ O2) also increase linearly with exercise
intensity, a strong linear relationship between RPE values
and these physiological variables is derived during CPET.
Indeed, the RPE scale is constructed around the fundamen-
tal assumption that physiological strain grows linearly with
exercise intensity, and that overall RPE values (i.e., undif-
ferentiated ratings representing an integration of many dif-
ferentiated perceptual signals from whole body, including
dyspnea) also follow the same linear increase (Borg 1998).
This assumption has been confirmed from a meta-analysis
involving 64 studies which showed that overall RPE were
significantly linearly correlated with a number of physi-
ological variables, e.g., V̇ O2 (r = 0.63) (Chen et al. 2002).
Consequently, effort perceptions from the RPE scale are
frequently monitored during CPET to assess the relation-
ship with physiological variables, such as V̇ O2 (Eston et al.
2005, 2006, 2008, 2012; Coquart et al. 2009; Faulkner and
Eston 2007; Faulkner et al. 2007, 2009). On the basis of
strong individual linear relationships between RPE, HR and
V̇ O2, Eston et al. (2005) proposed that extrapolation of the
individual linear regression between V̇ O2 and overall RPE
(obtained during sub-maximal exercises) to the theoretical
maximal RPE value (i.e., RPE20), could predict the peak
oxygen uptake (V̇ O2 peak). In addition to limiting the risk
of cardiovascular complications in CPET (e.g., myocardial
infarction or sustained ventricular tachycardia), a predictive
method may also reduce the extent of negative affect during
the higher exercise intensities of CPET.
High exercise intensities during maximal CPET cause
temporary discomfort and negative affect to the indi-
vidual (Sheppard and Parfitt 2008; Welch et al. 2007) and
indeed, the affective response to exercise (i.e., how pleas-
ant/unpleasant it is perceived to be) has been found to pre-
dict future exercise behavior (Williams et al. 2008, 2012).
Consequently, performing a maximal CPET prior to a
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Eur J Appl Physiol (2015) 115:365–372
rehabilitation program to directly measure V̇ O2 peak, may
elicit negative affect, which may in turn reduce the patient’s
adherence to the program. Consequently, rather than
directly measure V̇ O2 peak, individual linear regression
between V̇ O2 and overall RPE (e.g., during the first stages
of CPET) has been used to predict V̇ O2 peak in healthy
and/or active participants and in some clinical populations
(Coquart et al. 2014). This method is not generally applied
in COPD as dyspnea may account for considerable vari-
ance in overall RPE (arising from the integration of percep-
tual signals from whole body, including dyspnea) (Pandolf
et al. 1975), thereby reducing the accuracy of predicted V̇
O2 peak.
Therefore, the aims of this study were to: (1) test the
validity of predicting V̇ O2 peak from the individual linear
regression between V̇ O2 and overall RPE obtained during
the first stages of a sub-maximal CPET in healthy partici-
pants and in patients with COPD, and (2) compare predic-
tive accuracy in both populations.
Methods
Participants
Fifteen healthy participants (4 women; 3 physically active
participants) and 18 patients with COPD (4 women; none
physically active) participated in the study (Table 1), which
was approved by the appropriate authorities (CEPRO
2011-036). Participants had no prior experience with the
RPE scale. Among the patients with COPD, the severity
of airflow limitation was ‘mild’ in 5 patients, ‘moderate’
in 5 patients, ‘severe’ in 6 patients and ‘very severe’ in 2
patients. No patients used supplemental oxygen.
Materials and methods
Before CPET, anthropometric (i.e., body mass, height
and body mass index) and spirometric (i.e., forced expira-
tory volume in one second: FEV1 and forced vital capac-
ity: FVC) data were collected for each participant. Height
(m) was measured to the nearest centimeter with the patient
scantily dressed, without shoes, and was done in the morn-
ing. Body mass (kg) was measured at the same time to the
nearest 0.1 kg. Body mass index (kg m−2) was calculated
as body mass (kg) divided by the square of height (m).
FEV1 (L, volume of air exhaled from the lungs during the
first second of a forced expiratory maneuver) and FVC (L,
the maximal volume of air which can be forcibly exhaled
from the lungs after taking the deepest breath possible)
were assessed by spirometry. From these spirometric data,
the percentage of the vital capacity which is expired in the
Eur J Appl Physiol (2015) 115:365–372 367

Table 1  Anthropometric and spirometric data of the healthy participants and patients with chronic obstructive pulmonary disease (COPD)
Variable (units) Healthy Healthy Healthy Women Men with Patients with Women Men
women men participants with COPD COPD COPD (n = 8) (n = 25)
(n = 4) (n = 11) (n = 15) (n = 4) (n = 14) (n = 18)

Age (years) 46.5 ± 15.6 37.8 ± 13.5 39.9 ± 14.1 55.0 ± 6.5 58.7 ± 8.6 57.9 ± 8.1a 50.8 ± 12.0 49.4 ± 15.2
Height (m) 1.69 ± 0.09 1.79 ± 0.04 1.76 ± 0.07 1.59 ± 0.05 1.72 ± 0.07 1.69 ± 0.08a 1.64 ± 0.08 1.75 ± 0.07b
Body mass (kg) 71.0 ± 22.8 85.1 ± 20.5 81.3 ± 21.3 61.3 ± 19.9 83.7 ± 17.5 78.7 ± 19.9 66.1 ± 20.5 84.3 ± 18.5b
Body mass index (kg m−2) 25.0 ± 8.7 26.6 ± 6.4 26.1 ± 6.8 23.9 ± 6.3 28.3 ± 6.3 27.3 ± 6.4 24.5 ± 7.1 27.5 ± 6.3
FEV1 (L) 2.7 ± 0.4 4.1 ± 0.6 3.7 ± 0.8 1.3 ± 0.5 1.4 ± 0.5 1.4 ± 0.5a 2.0 ± 0.9 2.6 ± 1.4b
FEV1 (% predicted FEV1) 96.4 ± 13.7 99.2 ± 9.9 98.5 ± 10.6 56.1 ± 21.5 45.5 ± 15.4 47.9 ± 16.8a 76.3 ± 27.2 69.2 ± 30.1
FVC (L) 3.2 ± 0.5 4.9 ± 0.7 4.5 ± 1.0 2.1 ± 0.5 2.4 ± 0.7 2.4 ± 0.6a 2.7 ± 0.7 3.5 ± 1.4b
FVC (% predicted FVC) 95.8 ± 9.4 99.4 ± 12.9 98.4 ± 11.9 77.9 ± 14.0 60.1 ± 16.5 64.1 ± 17.3a 86.9 ± 14.6 77.4 ± 24.7
FEV1/FVC (%) 86.0 ± 7.5 82.7 ± 7.0 83.5 ± 7.0 59.7 ± 15.2 59.6 ± 14.0 59.6 ± 13.8a 72.8 ± 17.9 69.8 ± 16.2

FEV1 forced expiratory volume in one second, FVC forced vital capacity
a
  Significant difference between the groups (P < 0.05)
b
  Significant difference between the sexes (P < 0.05)

first second of maximal expiration (i.e., FEV1/FVC × 100)
was calculated. From FEV1, the severity of airflow limita-
tion in COPD according to the Global initiative for chronic
Obstructive Lung Disease (2014) was determined.
Prior to conducting the CPET, the RPE scale was pre-
sented and explained to participants. This scale was used
because it is the most frequently used tool to assess effort
perception in sport sciences (Eston 2012). The RPE scale
measures effort perception, which may be defined as the
intensity of subjective effort, stress, discomfort and/or
fatigue that is experienced during physical exercise (Noble
and Robertson 1996). The scale is a 15-point equidistant
interval tool, containing verbal descriptors of effort at RPE6
(no exertion at all), between RPE7 and RPE8 (extremely
light), RPE9 (very light), RPE11 (light), RPE13 (somewhat
hard), RPE15 (hard), RPE17 (very hard), RPE19 (extremely
hard) and RPE20 (maximal exertion).
Prior to performing the CPET, the following instructions
were read:
“While exercising we want you to rate your perception
of exercise, i.e., how heavy and strenuous the exercise feels
to you. Look at this rating scale; we want you to use this
scale from RPE6 to RPE20, where RPE6 below while means
‘no exertion at all’ and RPE20 means ‘maximal exertion’.
RPE9 corresponds to ‘very light’ exercise. For a normal,
healthy person it is like walking slowly at his or her own
pace for some minutes. RPE13 on the scale is ‘‘somewhat
hard’’ exercise, but it still feels OK to continue. RPE17
‘very hard’ is very strenuous. A healthy person can still go
on, but he or she really has to push him- or herself. It feels
very heavy, and the person is very tired. RPE19 on the scale
is an extremely strenuous exercise level. For most people
this is the most strenuous exercise they have ever experi-
enced. Try to appraise your feeling of exertion as honestly
as possible, without thinking about what the actual physi-
cal load is. Do not underestimate it, but do not overesti-
mate it neither. It is your own feeling of effort and exertion
that is important, not how it compares to other people’s.
What other people think is not important neither. Look at
the scale and the expressions and then give a number. Any
question?”
Following a 3-min rest period, participants performed
a CPET on an electromagnetically braked cycle ergometer
(Ergometrics 800, Ergoline®, Blitz, Germany) in accord-
ance with the American Thoracic Society (ATS)/American
College of Chest Physicians (ACCP) (2003). For healthy
participants, power output in the first minute (0 and 50 W
in women and men, respectively) was followed by 1-min
increments of 10 W (women) or 30 W (men). For the COPD
group, initial power output was set at 10 W in women and
20 W in men, with increments of 10 and 15 W, respectively.
The initial and subsequent increments in power output were
set to achieve an exercise duration of between 8 and 12 min.
A pedal rate of 60–70 rev min−1 was maintained through-
out CPET. The CPET ended at the point of volitional
exhaustion (i.e., the participant failed to maintain a pedal
rate above 60 rev min−1 for more than 5 s, unless the test
was terminated for medical reasons). Expired air was con-
tinuously recorded via a breath-by-breath system (Medis-
oft®, Sorinnes, Belgium), calibrated in accordance with
the manufacturer’s guidelines and averaged during the last
15 s of each stage. Overall RPE were collected during each
stage until RPE≥15. Only the RPE values inferior or equal
to RPE15 were collected because our main aim was to test
the validity of the individual linear regression between V̇ O2
and overall RPE≤15 to predict V̇ O2 peak. From RPE≥15, par-
ticipants were verbally encouraged until volitional exhaus-
tion. As a plateau phenomenon in V̇ O2 is rarely observed

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in patients with COPD, V̇ O2 peak (highest V̇ O2 observed)
during the last minute of CPET was determined. Exhaustion
was verified by following criteria: (1) respiratory exchange
ratio ≥ 1.15; (2) ventilatory reserve ≤10 % (i.e., theoretical
maximal ventilation = FEV1 × 35); (3) peak HR ≥ 90 % of
the theoretical maximal HR (i.e., 210 − 0.65 × age); and
(4) subjective exhaustion. In all cases at least two of the four
criteria were met.
Statistical analysis
Data are expressed as mean ± standard deviation (SD).
Normal Gaussian distributions of all data were verified
by the Shapiro–Wilk test and the homogeneity of vari-
ance was analyzed from the Levene’s test. Anthropometric
and spirometric data for each group were compared with
a two-way (clinical status: healthy participants vs. patients
with COPD × sex: women vs. men) analysis of variance
(ANOVA).
Percentages of V̇ O2 peak at different RPE values were
compared between groups with a two-way ANOVA (clini-
cal status × sex) for repeated measures (RPE7 vs. RPE9 vs.
RPE11 vs. RPE13 vs. RPE15).
To investigate whether sub-maximal RPE (RPE≤15)
could be used to predict V̇ O2 peak, the individual linear
regression between overall RPE and V̇ O2 was extrapolated
to the theoretical V̇ O2 peak at RPE19. The RPE19 (rather
than RPE20) was used as this value is frequently observed
to be the maximal RPE that an individual will generally
tolerate during exhaustive bouts of exercise (Faulkner and
Eston 2007; Faulkner et al. 2007). The equation used was:
V̇ O2 peak = a + b (RPE19).
The actual and predicted V̇ O2 peak were compared
through a two-way ANOVA (clinical status × sex). The
sphericity was checked by the Mauchly test. When the
sphericity was not met, the significance of F-ratios was
adjusted according to the Greenhouse–Geisser proce-
dure. The magnitude of these differences was assessed
by Hedge’s g. The association between the actual and
predicted V̇ O2 peak was tested with the Pearson product
moment correlation. The bias and 95 % limits of agree-
ment (LoA95 %) were computed according to the method
of Bland–Altman recently revised by Ludbrook (2010).
Before this procedure, the normality of the distribution of
the bias was confirmed with the Shapiro–Wilk test. Moreo-
ver, we tested the null hypothesis that the bias was not dif-
ferent from zero with the Student’s t test. Finally, the lack
of significant correlation between the bias and the mean
actual and predicted V̇ O2 peak was tested using a Bravais–
Pearson test.
Statistical significance was set at P < 0.05 and all analy-
ses were performed with the Statistical Package for the
Social Sciences (release 20.0, Chicago, IL, USA).
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Eur J Appl Physiol (2015) 115:365–372
Results
Anthropometric and spirometric data of each group accord-
ing to clinical status and sex are presented in Table 1.
The number of stages performed by healthy partici-
pants and patients with COPD until RPE≤15 was 6.1 ± 2.1
and 6.4 ± 2.0 stages, respectively. Moreover, at volitional
exhaustion, healthy participants performed 8.1 ± 1.7 stages
vs. 7.6 ± 1.9 stages in the patients with COPD. The num-
ber of stages was not significantly different between groups
(P > 0.05).
Percentages of V̇ O2 peak at RPE7, RPE9, RPE11, RPE13
and RPE15 are presented in Table 2. The percentage of V̇ O2
peak increased significantly with RPE values (P < 0.001).
However, no significant effect was noticed between groups
(women vs. men, P  = 0.696 and healthy participants vs.
patients with COPD, P = 0.086). Similarly, no interaction
effect was found.
Mean actual and predicted V̇ O2 peak were not sig-
nificantly different in healthy women (18.9 ± 4.1 vs.
20.4  ± 4.5 mL kg−1 min−1, respectively; g  = 0.23)
and men (28.9 ± 7.8 vs. 29.7 ± 8.5 mL kg−1 min−1,
respectively; g  = 0.09), or in women (15.2 ± 4.7 vs.
15.8  ± 5.0 mL kg−1 min−1, respectively; g  = 0.08) and
men (16.2 ± 4.4 vs. 17.4 ± 5.4 mL kg−1 min−1, respec-
tively; g  = 0.21) with COPD (P  = 0.067). However, a
significantly higher actual and predicted V̇ O2 peak were
observed in healthy participants compared to patients
with COPD (P  = 0.002). Moreover, significantly lower
actual and predicted V̇ O2 peak were obtained in women in
comparison with men (P  = 0.035). No interactions were
observed (P > 0.05).
The association between actual and predicted V̇
O2 peak, as well as the bias ± LoA95 % are shown in
Fig.  1 for healthy participants (r  = 0.954, P < 0.001;
−1.0 ± 4.0 mL kg−1 min−1), and in Fig. 2 for patients with
COPD (r = 0.890, P < 0.001; −1.0 ± 4.6 mL kg−1 min−1).
Discussion
This study observed no significant difference between
actual and predicted V̇ O2 peak in both healthy participants
and in patients with COPD. These results show that by
extrapolating the individual linear regression between V̇
O2 and overall RPE (obtained during the first stages of a
sub-maximal CPET) to RPE19, it is possible to predict V̇
O2 peak in healthy participants and in patients with COPD,
confirming previous studies in healthy and/or active par-
ticipants (Faulkner et al. 2007; 2009; Lambrick et al.
2009). Consequently, it may be suggested that following
a maximal CPET to determine if a patient with COPD
may follow a pulmonary rehabilitation program (i.e., no
Eur J Appl Physiol (2015) 115:365–372 369

Table 2  Percentage of peak oxygen uptake (% V̇ O2 peak) at different ratings of perceived exertion (RPE) in the healthy participants and patients
with chronic obstructive pulmonary disease (COPD)
Variable (units) Healthy Healthy Healthy Women with Men with Patients with Women Men
women men participants COPD COPD COPD (n = 8) (n = 25)
(n = 4) (n = 11) (n = 15) (n = 4) (n = 14) (n = 18)

V̇ O2 at RPE7 (%V̇ O2 peak) 33.4 ± 10.4 31.1 ± 14.9 31.7 ± 13.6 43.1 ± 19.2 41.5 ± 11.8 41.9 ± 13.1 38.2 ± 15.2 36.9 ± 14.0
V̇ O2 at RPE9 (%V̇ O2 peak) 45.8 ± 8.4 43.0 ± 13.2 43.7 ± 11.9 53.3 ± 15.1 52.6 ± 9.6 52.7 ± 10.5 49.5 ± 12.0 48.4 ± 12.1
V̇ O2 at RPE11 (%V̇ O2 peak) 58.1 ± 6.7 54.9 ± 11.6 55.7 ± 10.4 63.5 ± 11.2 63.6 ± 8.4 63.6 ± 8.7 60.8 ± 9.0 59.8 ± 10.7
V̇ O2 at RPE13 (%V̇ O2 peak) 70.5 ± 5.7 66.7 ± 10.4 67.7 ± 9.3 73.7 ± 7.9 74.7 ± 8.6 74.5 ± 8.2 72.1 ± 6.6 71.2 ± 10.1
V̇ O2 at RPE15 (%V̇ O2 peak) 82.8 ± 5.7 78.6 ± 9.6 79.8 ± 8.7 83.9 ± 6.2 85.7 ± 10.1 85.3 ± 9.3 83.4 ± 5.5 82.6 ± 10.3

Fig. 1  Left panel Association between actual and predicted peak Bland–Altman adapted by Ludbrook for the comparison between
oxygen uptake (V̇ O2 peak) in healthy participants. The dashed line is actual and predicted V̇ O2 peak in healthy participants. The dashed
the line of identity which corresponds to a perfect estimation of peak line is the bias. The thick lines are the 95 % limits of agreement
oxygen uptake. The thick line is the linear relationship. Right panel (LoA95 %)

contraindications to physical exercise), it is not neces-
sary to regularly repeat CPET to exhaustion to readjust
the exercise intensity (i.e., percentage of V̇ O2 peak). The
advantage of this is to avoid negative affect and limitation
of the risk of cardiovascular complications. Furthermore,
use of RPE≤15 (rather than RPE≤17) may be considered to
be more appropriate for sedentary and clinical populations
as it offers a compromise between the negative affect and
potentially greater risk of cardiovascular complications
associated with high exercise intensities during CPET, and
the gain of predictive accuracy using the large RPE range
(RPE≤17). Furthermore, in comparison to RPE≤17, the
RPE≤15 reduces the duration and overall cost of using sub-
maximal protocols.
The overall RPE represents an integration of perceptual
signals from metabolic, physiological and thermal stimuli
(Pandolf et al. 1975). These differentiated signals may not
act equivalently on the overall RPE, i.e., each differentiated
signal is assumed to carry a specific intensity weighting
with the most intense signal dominating the sensory inte-
gration process that forms the overall RPE. The highest dif-
ferentiated RPE determined at a given moment during exer-
cise, i.e., the “perceptual signal dominance”, is influenced
by several factors, including exercise intensity, modality
and habituation (Bolgar et al. 2010). It is not known how
differentiated perceptual signals from dyspnea contribute to
the determination of overall RPE in patients with COPD,
in whom dyspnea is a major symptom (O’Donnell et al.
2009). The present study reveals that the extrapolation of
the individual linear regression between V̇ O2 and overall
RPE provided an acceptable estimate of V̇ O2 peak which
was slightly higher by 6.3 % (i.e., 1.0 mL kg−1 min−1),
although this was not statistically significant. It is possible
that the differentiated RPE arising from dyspnea, rather
than overall RPE, may allow for an even more accurate
estimation of V̇ O2 peak. Indeed, several abnormal physi-
ological responses to CPET, including increased central
respiratory drive secondary to pulmonary gas exchange
(e.g., high fixed physiological dead space secondary to
increased ventilation–perfusion abnormalities) and meta-
bolic (e.g., metabolic acidosis secondary to skeletal mus-
cle deconditioning which increases peripheral muscle
metaboreceptor and mechanoreceptor activation) derange-
ments, as well as some mechanical factors (e.g., static and
dynamic pulmonary hyperinflation as a consequence of
expiratory flow limitation result in reduction of the resting

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Fig. 2  Left panel Association between actual and predicted peak
oxygen uptake (V̇ O2 peak) in patients with chronic obstructive pul-
monary disease (COPD). The dashed line is the line of identity which
corresponds to a perfect estimation of peak oxygen uptake. The thick
inspiratory capacity and inspiratory reserve volume such
that as tidal volume increases during CPET, and a critically
minimal inspiratory reserve volume is reached early), are
frequently found in patients with COPD (O’Donnell et al.
2009). These common abnormal physiological responses to
CPET in patients with COPD increase the dyspnea inten-
sity, and may limit exercise, leading to premature cessation
of CPET, specifically in patients who have a severe airflow
limitation. Consequently, it is possible that using the indi-
vidual linear regression between V̇ O2 and differentiated
RPE arising from dyspnea (which at least partially limits
exercise in patients with COPD), rather than an overall
RPE, may allow for greater accuracy for predicting V̇ O2
peak. However, further studies are necessary to confirm this
hypothesis.
In theory, as RPE20 is the theoretical maximal value on
the RPE scale, this value is generally expected at the CPET
end. However, numerous studies (Demello et al. 1987;
Eston et al. 2007; Coquart et al. 2012) have shown that
the theoretical maximal RPE (i.e., RPE 20) is infrequently
reported at volitional exhaustion during standard maximal
exercise testing (Eston 2012). Consequently, to predict V̇ O2
peak from the individual linear regression between overall
RPE and V̇ O2, several studies have shown that extrapola-
tion to RPE19 is accurate (Eston et al. 2012; Faulkner et
al. 2007; Morris et al. 2010). Accordingly, we have used
this generally tolerated maximal RPE value (i.e., RPE19)
rather than RPE20 to predict V̇ O2 peak. Several reasons
may explain why many participants fail to achieve RPE20 at
the CPET end. Firstly, as reminded by Faulkner and Eston
(2008) a high level of motivation is required to attain V̇ O2
peak during CPET and consequently, a lack of motivation
may lead to some participants prematurely stopping dur-
ing a CPET. Secondly, this “underestimation” of maximal
effort perception may also be explained by the conserva-
tion of a “reserve capacity”. Indeed, it has been suggested
13
Eur J Appl Physiol (2015) 115:365–372
line is the linear relationship. Right panel Bland–Altman adapted by
Ludbrook for the comparison between actual and predicted V̇ O2 peak
in patients with COPD. The dashed line is the bias. The thick lines
are the 95 % limits of agreement (LoA95 %)
that participants will maintain a reserve capacity during
maximal exercise testing, presumably to prevent any cata-
strophic failure of homeostasis (Swart et al. 2009).
The current results reveal also that the accuracy of
predicted V̇ O2 peak was better in healthy participants
compared to patients with COPD. Indeed, although not
statistically significant, predicted V̇ O2 peak was overes-
timated by 3.7 and 6.3 % in healthy and COPD, respec-
tively. Moreover, larger LoA95 % was noticed in patients
with COPD in comparison with healthy participants (4.0
vs. 4.6 mL kg−1 min−1, respectively; Figs. 1, 2). The
lower accuracy in patients with COPD may be explained
by symptoms which will have limited the progression to
maximal exercise as patients with COPD are often symp-
tom-limited, and may stop exercise before reaching physi-
ological limits (American Thoracic Society (ATS)/Ameri-
can College of Chest Physicians (ACCP) 2003). Indeed,
although dyspnea is a common symptom in patients with
COPD, other symptoms including leg discomfort, chest
pain, or fatigue will also limit the exercise response (Ham-
ilton et al. 1995; Jones and Killian 2000). Additional stud-
ies are necessary to examine the influence of different
symptoms limiting exercise on predicted V̇ O2 peak accord-
ing to severity of airflow limitation in patients with COPD.
The present study observed a larger LoA95 % in patients
with COPD compared to healthy participants, suggesting
a lower accuracy for predicting V̇ O2 peak in this popula-
tion. Possible improvements in the prediction of V̇ O2 peak
may be obtained from a second exercise test. Indeed, it is
generally recognized that the accuracy of predicting V̇ O2
peak from the individual relationship between V̇ O2 and
RPE is better following an initial exercise test in seden-
tary subjects, suggesting a “practice” effect (Eston et al.
2008; Faulkner et al. 2007). Consequently, V̇ O2 peak may
be predicted more accurately with repeated exercise test-
ing during a pulmonary rehabilitation program, which uses
Eur J Appl Physiol (2015) 115:365–372 371
the individual relationship between RPE and V̇ O2. Further
studies are necessary to confirm this hypothesis.
Conclusion
The present study reveals that it is possible to extrapolate
the individual linear regression between V̇ O2 and overall
RPE≤15 (obtained during the first stages of a sub-maximal
CPET) to RPE19, in order to predict V̇ O2 peak in healthy
participants and patients with COPD.
Conflict of interest  No conflicts for all authors.
References
American Thoracic Society (ATS)/American College of Chest Physi-
cians (ACCP) (2003) ATS/ACCP statement on cardiopulmonary
exercise testing. Am J Respir Crit Care Med 167:211–277
Bolgar MR, Baker CE, Goss FL, Nagle E, Robertson RJ (2010) Effect
of exercise intensity on differentiated and undifferentiated ratings
of perceived exertion during cycle and treadmill exercise in recre-
ationally active and trained women. J Sports Sci Med 9:557–563
Borg G (1970) Perceived exertion as an indicator of somatic stress.
Scand J Rehabil Med 2:92–98
Borg GA (1982) Psychophysical bases of perceived exertion. Med Sci
Sports Exerc 14:377–381
Borg G (1998) Borg’s Perceived exertion and pain scales. Human
Kinetics, Champaign, IL
Chen MJ, Fan X, Moe ST (2002) Criterion-related validity of the
Borg ratings of perceived exertion scale in healthy individuals: a
meta-analysis. J Sports Sci 20:873–899
Coquart JB, Lemaire C, Dubart A-E, Douillard C, Luttenbacher D-P,
Wibaux F, Garcin M (2009) Prediction of peak oxygen uptake
from sub-maximal ratings of perceived exertion elicited dur-
ing a graded exercise test in obese women. Psychophysiology
46:1150–1153
Coquart JB, Eston R, Nycz M, Grosbois J-M, Garcin M (2012) Esti-
mation of maximal oxygen uptake from ratings of perceived exer-
tion elicited during sub-maximal tests in competitive cyclists.
Arch Sci Med 171:165–172
Coquart JB, Garcin M, Parfitt G, Tourny-Chollet C, Eston RG (2014)
Prediction of maximal or peak oxygen uptake from ratings of
perceived exertion. Sports Med 44:563–578
Demello JJ, Cureton KJ, Boineau RE, Singh MM (1987) Ratings of
perceived exertion at the lactate threshold in trained and untrained
men and women. Med Sci Sports Exerc 19:354–362
Eston R (2012) Use of ratings of perceived exertion in sports. Inter J
Sports Physiol Perf 7:175–182
Eston RG, Lamb KL, Parfitt G, King N (2005) The validity of predict-
ing maximal oxygen uptake from a perceptually-regulated graded
exercise test. Eur J Appl Physiol 94:221–227
Eston RG, Faulkner JA, Mason EA, Parfitt G (2006) The validity of
predicting maximal oxygen uptake from perceptually regulated
graded exercise tests of different durations. Eur J Appl Physiol
97:535–541
Eston R, Faulkner J, St Clair Gibson A, Noakes T, Parfitt G (2007)
The effect of antecedent fatiguing activity on the relationship
between perceived exertion and physiological activity during a
constant load exercise task. Psychophysiology 44:779–786
Eston R, Lambrick D, Sheppard K, Parfitt G (2008) Prediction of
maximal oxygen uptake in sedentary males from a perceptu-
ally regulated, sub-maximal graded exercise test. J Sports Sci
26:131–139
Eston R, Evans H, Faulkner J, Lambrick D, Al-Rahamneh H, Parfitt
G (2012) A perceptually regulated, graded exercise test predicts
peak oxygen uptake during treadmill exercise in active and sed-
entary participants. Eur J Appl Physiol 112:3459–3468
Faulkner J, Eston R (2007) Overall and peripheral ratings of per-
ceived exertion during a graded exercise test to volitional exhaus-
tion in individuals of high and low fitness. Eur J Appl Physiol
101:613–620
Faulkner J, Eston R (2008) Perceived exertion research in the 21st
century: developments, reflections and questions for the future. J
Exerc Sci Fit 6:1–14
Faulkner J, Parfitt G, Eston R (2007) Prediction of maximal oxygen
uptake from the ratings of perceived exertion and heart rate dur-
ing a perceptually-regulated sub-maximal exercise test in active
and sedentary participants. Eur J Appl Physiol 101:397–407
Faulkner JA, Lambrick D, Parfitt G, Rowlands AV, Eston RG (2009)
Prediction of maximal oxygen uptake from the Astrand-Ryh-
ming nomogram and ratings of perceived exertion. In: Atkinson
G, Reilly T (eds) Contemporary sport, leisure and ergonomics.
Routledge, London, pp 197–214
Global initiative for chronic obstructive lung disease (2014) Global
strategy for the diagnosis management, and prevention of chronic
obstructive pulmonary disease: updated 2014
Hamilton AL, Killian KJ, Summers E, Jones NL (1995) Muscle
strength, symptom intensity, and exercise capacity in patients
with cardiorespiratory disorders. Am J Respir Crit Care Med
152:2021–2031
Jones NL, Killian KJ (2000) Exercise limitation in health and disease.
N Engl J Med 343:632–641
Lambrick DM, Faulkner JA, Rowlands AV, Eston RG (2009) Predic-
tion of maximal oxygen uptake from submaximal ratings of per-
ceived exertion and heart rate during a continuous exercise test:
the efficacy of RPE 13. Eur J Appl Physiol 107:1–9
Ludbrook J (2010) Confidence in Altman–Bland plots: a critical
review of the method of differences. Clin Exp Pharmacol Physiol
37:143–149
Morris M, Lamb KL, Hayton J, Cotterrell D, Buckley J (2010) The
validity and reliability of predicting maximal oxygen uptake from
a treadmill-based sub-maximal perceptually regulated exercise
test. Eur J Appl Physiol 109(5):983–988
Noble BJ, Robertson RJ (1996) Perceived exertion. Human Kinetics,
Champaign
O’Donnell DE, Lam M, Webb KA (1998) Measurement of symptoms,
lung hyperinflation, and endurance during exercise in chronic
obstructive pulmonary disease. Am J Respir Crit Care Med
158:1557–1565
O’Donnell DE, Ora J, Webb KA, Laveneziana P, Jensen D (2009)
Mechanisms of activity-related dyspnea in pulmonary diseases.
Respir Physiol Neurobiol 30:116–132
Pandolf KB, Burse RL, Goldman RF (1975) Differentiated ratings
of perceived exertion during physical conditioning of older indi-
viduals using leg-weight loading. Percept Mot Skills 40:563–574
Sheppard KE, Parfitt G (2008) Patterning of physiological and affec-
tive responses during a graded exercise test in sedentary men and
boys. J Exerc Sci Fit 6:121–129
Swart J, Lamberts RP, Lambert MI, Lambert EV, Woolrich RW, John-
ston S, Noakes TD (2009) Exercising with reserve: exercise regu-
lation by perceived exertion in relation to duration of exercise and
knowledge of endpoint. Brit J Sports Med 43:775–781
Welch AS, Hulley A, Ferguson C, Beauchamp MR (2007) Affec-
tive responses of inactive women to a maximal incremental
13

372
exercise test: a test of the dual-mode model. Psychol Sport Exerc
8:401–423
Williams DM, Dunsiger S, Ciccolo JT, Lewis BA, Albrecht AE, Mar-
cus BH (2008) Acute affective response to a moderate-intensity
exercise stimulus predicts physical activity participation 6 and
12 months later. Psychol Sport Exerc 9:231–245
13
Eur J Appl Physiol (2015) 115:365–372
Williams DM, Dunsiger S, Jennings EG, Marcus BH (2012) Does
affective valence during and immediately following a 10-min
walk predict concurrent and future physical activity? Ann Behav
Med 44:43–51
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